Multiple drilling is not effective in reducing the rate of conversion to Total hip Arthroplasty in early-stage nontraumatic osteonecrosis of the femoral head: a case-control comparative study with a natural course

Bone Scintigraphy Prediction of Postoperative Femoral Head Avascular Necrosis in Children With Hip Trauma and Slipped Capital Femoral Epiphysis

BACKGROUND

Femoral head avascular necrosis (AVN) is a devastating complication that can occur in the setting of trauma to the pediatric hip. Bone scintigraphy (BoS) can be used to evaluate femoral head perfusion, but current evidence in support of its use in the pediatric population is lacking. The purpose of this study was to evaluate the sensitivity and specificity of BoS to diagnose femoral head AVN in children.

METHODS

We retrospectively reviewed patients who underwent BoS to assess femoral head perfusion following treatment of traumatic femoral neck fracture, hip dislocation, or SCFE at a single pediatric hospital. All patients had a minimum radiographic follow-up of 1 year. Assessment of intraoperative femoral head perfusion was also recorded if performed. Results of BoS and intra-op assessments were compared with RAVN (radiographic findings of AVN) at final follow-up.

RESULTS

Forty-eight hips were included, and 75% were male. The mean age at the time of surgery was 12.5±1.6 years. The mean age at BoS was 12.7±1.7 years. The mean follow-up was 23.3±13.1 months. RAVN developed in 15% (7/48) of hips. Nine hips had an abnormal BoS: 7 hips had absent perfusion and 2 hips had diminished perfusion. All 7 hips with absent perfusion on BoS went on to develop RAVN with collapse. Neither hip with diminished perfusion on BoS went on to femoral head collapse. No hip with normal BoS developed radiographic evidence of AVN at the final follow-up. BoS demonstrating absent perfusion had a sensitivity of 100% and a specificity of 95% in predicting RAVN. Evidence of femoral head perfusion at the time of surgery (drilling or IOP) had a sensitivity of 17% and a specificity of 80% in predicting RAVN.

CONCLUSIONS

BoS demonstrates high sensitivity and specificity for predicting postoperative RAVN. Clinicians should have increased suspicion of impending femoral head collapse if there is absent perfusion on BoS at 6 to 12 weeks post-op, even with evidence of preserved femoral head perfusion at the time of surgery.

Hip joint-preserving strategies for treating osteonecrosis of the femoral head: From nonoperative to operative procedures

Osteonecrosis of the femoral head (ONFH) has an exceedingly high prevalence and disability rate, causing a tremendous socioeconomic burden. The prevalence of ONFH is increasing, while the population of the patients with ONFH is becoming younger. Once the femoral head collapses, treatment becomes difficult and often requires a hip joint replacement, which is not favorable for young patients. Therefore, hip joint-preserving treatments at an early stage of ONFH are particularly important. This study provides a comprehensive review on hip-preserving strategies for treating ONFH, including nonoperative treatments (e.g., protective weight bearing, hyperbaric oxygen, pulsed electromagnetic, extracorporeal shockwave, bisphosphonate, anticoagulants, hypolipidemics, vasodilators, and traditional Chinese medicine) and operative treatments (e.g., core decompression, osteotomy, bone grafting, mesenchymal stem cell transplantation, tantalum rods, and tissue engineering). Nonoperative treatments aim to slow down the progression of the disease and delay the need for joint replacement; however, they usually cannot effectively prevent the progression of the disease, except in cases of small necrosis areas (<10 %). Additionally, nonoperative treatments have unclear mechanisms that require further investigation. In contrast, operative treatments may stop the negative outcomes of necrosis and therefore appear to be more promising. Currently, an emerging area in operative treatments is regenerative medicine, which could promote the generation of bone tissues and blood vessels and restore hip joint function to pre-necrotic levels as much as possible. This review seeks to not only provide an important reference for clinicians when choosing appropriate strategies for treating ONFH but also offer certain guidance for future basic research in developing ONFH treatments.

The translational potential of this article

The incidence of ONFH is increasing, and patients are becoming younger on average. Therefore, the development of hip joint-preserving strategies to treat ONFH at earlier stages is urgently needed, particularly for young patients. However, a comprehensive review is lacking regarding the currently-available hip joint-preserving strategies and their effectiveness. This study is motivated to fill this gap and serve as an important reference for clinicians in choosing appropriate strategies to treat ONFH.

A radiomics and deep learning nomogram developed and validated for predicting no-collapse survival in patients with osteonecrosis after multiple drilling

PURPOSE

Identifying patients who may benefit from multiple drilling are crucial. Hence, the purpose of the study is to utilize radiomics and deep learning for predicting no-collapse survival in patients with femoral head osteonecrosis.

METHODS

Patients who underwent multiple drilling were enrolled. Radiomics and deep learning features were extracted from pelvic radiographs and selected by LASSO-COX regression, radiomics and DL signature were then built. The clinical variables were selected through univariate and multivariate Cox regression analysis, and the clinical, radiomics, DL and DLRC model were constructed. Model performance was evaluated using the concordance index (C-index), area under the receiver operating characteristic curve (AUC), net reclassification index (NRI), integrated discrimination improvement (IDI), calibration curves, and Decision Curve Analysis (DCA).

RESULTS

A total of 144 patients (212 hips) were included in the study. ARCO classification, bone marrow edema, and combined necrotic angle were identified as independent risk factors for collapse. The DLRC model exhibited superior discrimination ability with higher C-index of 0.78 (95%CI: 0.73-0.84) and AUC values (0.83 and 0.87) than other models. The DLRC model demonstrated superior predictive performance with a higher C-index of 0.78 (95% CI: 0.73-0.84) and area under the curve (AUC) values of 0.83 for 3-year survival and 0.87 for 5-year survival, outperforming other models. The DLRC model also exhibited favorable calibration and clinical utility, with Kaplan-Meier survival curves revealing significant differences in survival rates between high-risk and low-risk cohorts.

CONCLUSION

This study introduces a novel approach that integrates radiomics and deep learning techniques and demonstrates superior predictive performance for no-collapse survival after multiple drilling. It offers enhanced discrimination ability, favorable calibration, and strong clinical utility, making it a valuable tool for stratifying patients into high-risk and low-risk groups. The model has the potential to provide personalized risk assessment, guiding treatment decisions and improving outcomes in patients with osteonecrosis of the femoral head.

Network meta-analysis of invasive treatment for early-stage osteonecrosis of the femoral head

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a common disabling disease in orthopedics. Blocking the progression of ONFH in the early stage is essential for avoiding total hip replacement.

PURPOSES

The purpose of this study is to evaluate the effect of invasive treatment on early-stage ONFH.

METHODS

According to the PRISMA guidelines, relevant English databases were searched in August 2022 to collect published research. Extract result indicators and conduct network meta-analysis using R software.

RESULTS

A total of 15 RCTs were included. All patients were diagnosed with early-stage ONFH. The surface under the cumulative ranking curve (SUCRA) showed that CD + BMMSC and CD + PRP were the most effective in improving HHS. The results of the league table showed that CD + BMMSC was superior to CD alone. Meanwhile, the SUCRA for FR showed that CD + BG + BMMSC was the most likely to be the most effective in reducing FR. The league table revealed that CD + BG, CD + BG + BMMSC, and CD + BMMSC were superior to CD alone, with statistically significant differences.

CONCLUSION

Considering the HHS and FR, CD + BMMSC may be the optimal treatment option to effectively delay the progression of ONFH and restore the postoperative function of patients.

REGISTRATION NUMBER

The study protocol has been registered on the PROSPERO platform (CRD42023380169).

The indications for core decompression surgery in patients with ARCO stage I-II osteonecrosis of the femoral head: a new, comprehensive prediction system

BACKGROUND

Core decompression (CD) is considered the most popular treatment method for patients with Association Research Circulation Osseous (ARCO) stage I-II osteonecrosis of the femoral head (ONFH). However, the definitive indication for CD is currently not well established.

METHODS

This was a retrospective cohort study. Patients who were diagnosed with ARCO stage I-II ONFH and who underwent CD were included. According to the prognosis, the patients were divided into two groups: collapse of the femoral head after CD and noncollapse of the femoral head. Independent risk factors for the failure of CD treatment were identified. Subsequently, a new scoring system that included all these risk factors was built to help estimate the individual risk of CD failure in patients who were planning to undergo CD.

RESULTS

The study included 1537 hips after decompression surgery. The overall failure rate of CD surgery was 52.44%. Seven independent prognostic factors for failed CD surgery were identified, such as male sex (HR = 75.449; 95% confidence interval (CI), 42.863-132.807), Aetiology (Idiopathic HR = 2.762; 95% CI, 2.016-3.788, Steroid-induced HR = 2.543; 95% CI, 1.852-3.685), if the patient had a seated occupation (HR = 3.937; 95% CI, 2.712-5.716), age (HR = 1.045; 95% CI, 1.032-1.058), haemoglobin level (HR = 0.909; 95% CI, 0.897-0.922), disease duration (HR = 1.217; 95% CI, 1.169-1.267) and the combined necrosis angle (HR = 1.025; 95% CI, 1.022-1.028). The final scoring system included these seven risk factors, and the area under the curve of this scoring system was 0.935 (95% confidential interval = 0.922-0.948).

CONCLUSION

This new scoring system might provide evidence-based medical proof for determining whether a patient with ARCO stage I - II ONFH might benefit from CD surgery. This scoring system is crucial for making clinical decisions. Consequently, this scoring system is recommended before CD surgery, which could help determine the potential prognosis of patients.

Multiple Drilling with Recombinant Human Bone Morphogenetic Protein-2 in Korean Patients with Non-Traumatic Osteonecrosis of the Femoral Head: A Prospective Randomized Pilot Study with a Minimum Two-Year Follow-Up

We sought to determine whether multiple drilling (MD) combined with the injection of recombinant human bone morphogenetic protein-2 (rhBMP-2) and β-tricalcium phosphate (β-TCP) could improve survival of the femoral head in pre-collapse lesions of non-traumatic osteonecrosis of the femoral head (ONFH) as compared with MD alone. We conducted a single-site, off-label, comparative and prospective cohort study between November 2017 and May 2019. We enrolled 25 hips (25 patients) with non-traumatic ONFH (Ficat–Arlet stage 2A or less). We performed a survival analysis, and the primary outcome was the occurrence of femoral head collapse on follow-up radiograph. Our cohort consisted of 11 men and 9 women of age 52.5 ± 8.8 years and a body mass index of 24.3 ± 3.0 kg/m². The femoral heads were preserved in 9 hips (45.0%) and collapsed in 11 hips (55.0%) at the final follow-up; mean survival to collapse was 6.9 (range 2.8–13.5) months. There were no significant differences in the survival of the femoral head between the MD alone group and the MD with rhBMP-2 and β-TCP group (five hips survived, 50% vs. four hips survived, 40%, respectively; p = 0.83). MD combined with the injection of rhBMP-2 and β-TCP did not improve femoral head survival compared to MD alone in the pre-collapse non-traumatic ONFH lesion.

Treatment of non-traumatic avascular necrosis of the femoral head (Review)

Non-traumatic osteonecrosis of the femoral head is the main cause of disability in young individuals and incurs major health care expenditure. The lifestyle changes in recent years, especially increased use of hormones and alcohol consumption, has greatly increased the incidence of femoral head necrosis. The underlying causes and risk factors of osteonecrosis of the femoral head are increasingly being elucidated, which has led to the development of novel surgical and non-surgical treatment options. Although the main goal of any treatment method is prevention and delaying the progression of disease, there is no common consensus on the most suitable method of treatment. The present review discussed the latest developments in the etiology and treatment methods for femoral head necrosis.